Literature Review Outline: To ensure that students are on track, submit a 2‐3 page double‐spaced APA formatted justification for your topic of interest. This justification should be written in formal

Clinical Impact Statement Obstructive sleep apnea (OSA) is very often comorbid with both posttraumatic stress disorder (PTSD) and substance use disorders (SUD). Unfortunately, due to the limitations of self-report OSA screeners and atypical presentation of OSA in individuals with SUD/PTSD, OSA often goes undiag- nosed for individuals with SUD/PTSD. Our study found that OSA diagnostic testing was feasible and acceptable to participants in a residential treatment program for SUD/PTSD, and effective in diagnosing OSA. Diagnosing OSA on a residential unit for SUD/PTSD is a necessaryfirst step to treating OSA and may help improve long-term outcomes for individuals with SUD/PTSD.

Keywords:veteran, PTSD, SUD, OSA, CPAP This article was published Online First September 2, 2021.

Peter J. Colvonen https://orcid.org/0000-0003-0222-8781 Jae E. Park https://orcid.org/0000-0002-0197-0012 Sonya B. Norman https://orcid.org/0000-0002-4751-1882 This study was funded by Veterans Affairs RR&D CDA Grant #1lK2Rx002120-01 to Peter J. Colvonen and Veterans Affairs CSR&D merit Grant NURA-011-11F to Sonya B. Norman. This material is the result of work supported by a UCSD Academic Senate Pilot Grant. Peter J.Colvonen is partly funded by Veterans Affairs RR&D CDA Grant 1lK2Rx002120-01.

The views expressed in this article are those of the authors only and do not reflect the official policy or position of the institutions with which the authors are affiliated, the Department of Veterans Affairs, nor the United States Government.

None of the authors have any competingfinancial interests to disclose.

Correspondence concerning this article should be addressed to Peter J.

Colvonen, VA San Diego Healthcare System, 3350 La Jolla Village Drive (116B), San Diego, CA 92161, United States. Email:[email protected] 178 Psychological Trauma:

Theory, Research, Practice, and Policy In the public domain2022, Vol. 14, No. 2, 178–185 ISSN: 1942-9681https://doi.org/10.1037/tra0001066 Substance use disorders (SUD) and posttraumatic stress disor- der (PTSD) are highly comorbid (Kessler et al., 2005;Najavits et al., 2010), and this comorbidity is associated with worse treatment outcomes for both disorders, greater risk of homelessness, increased disease burden, higher suicidal ideation and attempted suicide (Norman et al., 2018), and greater functional disability than having a single disorder (Calabrese et al., 2011;Driessen et al., 2008;Norman et al., 2016;Possemato et al., 2010). In addi- tion, both Veterans Affairs (VA) and community clinicians report significant challenges in treating comorbid SUD/PTSD individuals due to higher drop-out rates, more severe symptoms, and lower motivation (Najavits et al., 2010). Residential treatment is an appropriate level of care for individuals with severe PTSD and/or SUD (Haller et al., 2019) with upward of 40% of individuals seek- ing SUD treatment receiving residential care at some point (Stah- ler et al., 2016;Substance Abuse and Mental Health Services Administration, 2008). A residential setting offers an array of inte- grated treatment options to patients at a critical time in recovery and may be an optimal place to diagnose and treat comorbid disor- ders that can negatively affect both SUD and PTSD outcomes such as obstructive sleep apnea (OSA). Unfortunately, OSA diag- nostic testing is not a part of standard care in PTSD, SUD, or resi- dential treatment. Our study presents data on the feasibility and acceptability of implementing objective OSA diagnostic testing on a residential SUD treatment program for veterans with PTSD.

Sleep disordered breathing is a spectrum (Schwab et al., 1998) ranging from mild upper airway resistance (e.g., snoring) to severe OSA. OSA is associated with sleep fragmentation and is defined by repeated episodes of apneas (pauses in breathing) and hypo- pneas (shallow breathing) with decreases in blood oxygenation during sleep. The apnea-hypopnea index (AHI) is derived by cal- culating the number of apneas and hypopneas per hour of sleep, and is the most commonly used metric of OSA severity, with mild OSA starting at AHI$5. OSA in veterans is associated with neu- rocognitive decline, hypertension, increased cardiovascular mor- tality, stroke, heart attacks, andfinancial burden on the health care system (Jennum & Kjellberg, 2011;Redline et al., 2010;Young et al., 2008). Furthermore, OSA is associated with more depression, anxiety, PTSD, SUD, psychosis, suicidal ideation, bipolar disor- der, and dementia compared to veterans without OSA (Sharafkha- neh et al., 2005).

A systematic review of OSA prevalence in the general popula- tion found OSA ranged from 9% to 38%, and OSA risk increased with age and higher body mass index (BMI;Senaratna et al., 2017). Rates of OSA are significantly higher among veterans, with studies indicating diagnostic rates ranging between 67% to 83% (Krakow et al., 2006;Lettieri et al., 2016;Yesavage et al., 2012).

Furthermore, both SUD and PTSD increase risk of OSA. A meta- analysis of veterans with PTSD found OSA prevalence was 75.7% (AHI$5;Zhang et al., 2017). Among individuals with any SUD, 53.3% were screened as being high risk for OSA (Mahfoud et al., 2009), with increased substance use severity increasing risk of OSA (Rose et al., 2014).

While it is not entirely clear why veterans with PTSD present with higher rates of OSA compared to nonveterans without PTSD (Colvonen et al., 2015), there is convincing evidence that long- term alcohol ingestion and opioid use are important factors in pathogenesis of OSA (Le Bon et al., 1997;Vitiello et al., 1990; Wang & Teichtahl, 2007). For example, even after a single drink,normal sleepers can develop snoring and even exhibit breathing events resulting in oxygen desaturations (Block & Hellard, 1987).

Alcohol relaxes upper airway dilator muscles, which increases air- way obstruction and increases nasal and pharyngeal resistance (Scanlan et al., 2000;Young et al., 2002) and prolongs the time required to arouse or awaken after an apnea occurs (Dawson et al., 1993;Robinson et al., 1985). Even during abstinence, individuals with SUD are more likely than controls to have OSA (Le Bon et al., 1997;Mamdani et al., 1989;Robinson et al., 1985).

Research has demonstrated the detrimental impact of OSA on both SUD and PTSD outcomes. A retrospective study of veterans who had completed cognitive processing therapy, an evidence- based treatment for PTSD, found that those with untreated OSA (n= 69) showed less PTSD symptom improvement than those without OSA(N= 276;Mesa et al., 2017). However, those with OSA treated with positive airway pressure (PAP) showed more improvement in PTSD symptoms than those who were not treated (Reist et al., 2017). Both studies suggest that OSA screening/diag- nostic testing and treatment should be part of thefirst-line treat- ment for individuals with PTSD.

There have been no studies examining the effect of untreated or treated OSA on relapse. However, there is circumstantial evidence that OSA may influence relapse rates. First, OSA is strongly linked to fragmented sleep (Antic et al., 2011), and it has been shown that disrupted sleep architecture predicts relapse among individuals abstinent from alcohol (Brower et al., 2001) and other substances (e.g., opioids and methamphetamines;Angarita et al., 2016). Second, OSA is linked with other factors involved in relapse, including deficits in most aspects of executive function- ing, decreased processing speed, increased perseverative responses or behaviors, impulsivity, and difficulty with problem solving (Gagnon et al., 2014). Finally, untreated OSA is linked to lower sleep efficiency (Williams et al., 2015), which is associated with more frequent and larger moodfluctuations (El-Ad & Lavie, 2005), thus potentially placing SUD patients further at risk for relapse (Brower, 2003). Studies are needed to clarify how OSA may influence relapse rates.

Despite the detrimental effects of untreated OSA, it continues to be undiagnosed and untreated in many veterans, with estimates of 80% to 90% of veterans with OSA remaining undiagnosed (Alexander et al., 2016). There are two reasons for this: First, the symptoms of OSA (e.g., daytime fatigue, poor concentration, trou- ble sleeping, irritability) are often mistaken for the“primary disor- der”(e.g., SUD or PTSD), and thus OSA is not even considered as a contributor (Colvonen, Straus, et al., 2018). Second, there is sub- stantial evidence that OSA is increasing in younger veterans with co-occurring mental health disorders who do not have the classic risk factors (e.g., older age, overweight or obese per BMI), so OSA becomes difficult to identify (Colvonen et al., 2015;Rezaei- talab et al., 2018;Williams et al., 2015 ). As such, self-report OSA screening questionnaires, like the STOP-BANG or Berlin, that rely heavily on age, blood pressure, and BMI, are shown to be poor predictors of OSA in all veterans (Kunisaki et al., 2014; McMahon et al., 2017) as well as specifically among veterans with PTSD (Lyons et al., 2021). This suggests the need for objective OSA diagnostic testing among veterans.

The literature suggests that residential treatment is effective in treating mental health disorders (Zhang et al., 2003) and is the appropriate level of care for individuals with severe SUD or PTSD DIAGNOSING OSA AMONG VETERANS WITH SUD AND PTSD 179 (Haller et al., 2019). More information is needed about specific programmatic elements that could increase effective outcomes and maximize successful long-term continued care (Proctor & Hersch- man, 2014). Due to the stable environment and frequent contact between the treatment team and the patient, the residential setting may be a more effective environment than outpatient settings for diagnosing and treating co-occurring OSA (Colvonen, Ellison, et al., 2018). PAP is the gold-standard treatment for OSA, with meta-analytic reports showing decreased sleep fragmentation and improvement in daytime sleepiness and functioning across a host of domains (Patil et al., 2019). Meta-analyses show significant decreases in apnea/hypopneas with PAP use with very large effect sizes (Schwartz et al., 2018). Increasing accessibility to evidence- based care for OSA in a residential setting may be a critical path- way for treating OSA and thereby potentially improving SUD/ PTSD treatment outcomes. However, it is unclear whether objec- tive testing of OSA, a necessaryfirst step to treatment, would be feasible on a residential unit for veterans with SUD and PTSD.

Our study examined the feasibility and acceptability of objec- tive OSA diagnostic testing in a residential treatment unit for vet- erans with SUD and PTSD. We presentfindings on OSA prevalence and the relation between OSA and SUD/PTSD symp- toms. We hypothesized that objective OSA testing would be feasi- ble and acceptable. We also hypothesized that veterans with untreated OSA would have more severe SUD and PTSD symp- toms than those without OSA or with treated OSA. Finally, we make suggestions as to how residential units can implement OSA diagnostic testing and integrate PAP treatment. Methods Program Description The study took place in the Substance Abuse Residential Reha- bilitation Treatment Program (SARRTP) at the VA San Diego Health care System (VASDHS), a 14-bed residential substance use treatment program that also offers PTSD treatment for veter- ans with comorbid SUD and PTSD. The treatment team consisted of a clinical psychologist, psychiatrist, addiction therapists, nurs- ing staff, and social workers.

The program was 28 to 35 days in duration (seven-day extensions were offered to veterans engaging in intensive individual PTSD treat- ment). Unit programming consists of cognitive–behavioral therapy groups for treating SUD, introducing new skills (e.g., anger manage- ment), engaging in experientially based activities (e.g., mindfulness/ relaxation), and other recovery-oriented programming (e.g., living skills, job skills). Patients diagnosed with PTSD related to any trauma type are offered services on the PTSD track and receive psy- choeducation about PTSD and the interplay of SUD and PTSD, attend a cognitive restructuring group where PTSD-related beliefs are addressed, and take part in an in-vivo group where they practice group exposures to commonly avoided situations (e.g., sitting in a crowded waiting room). Some veterans are offered intensive individ- ual evidence-based PTSD treatment three times a week.

Participants All veterans participating in the PTSD track on the SARRTP unit at the VASDHS were offered participation in this study. Theonly exclusion criterion was unmanaged symptoms of psychosis, based on the discretion of the PTSD track clinical psychologist.

Recruitment occurred between February 2019 and March 2020. Of the 60 veterans admitted to the unit, 47 veterans (78%) consented.

Of the 47 veterans who consented, 2 veterans stated they did not want to be a part of the study after signing the consent. Data are presented on the remaining 45 veterans whofilled out question- naires and wore the OSA testing equipment. SeeTable 1for demographics. Procedures All research was approved by the institutional review board at the VASDHS. Veterans admitted onto the PTSD track on SARRTP were informed about the study from their SARRTP pro- vider during a one-on-one treatment planning session. Participants who expressed interest met with a study coordinator to learn more about OSA diagnostic testing procedures and were given the op- portunity to ask questions. Veterans who gave written consent to participate were given a home sleep apnea test (HSAT) overnight portable monitor for the diagnosis of OSA. We used the NOX T3 for our HSAT. Participants alsofilled out a daily sleep diary for seven days, and self-report measures (PTSD Checklist, Substance Use Inventory, Alcohol Use Disorder Identification Test, Client Table 1 Demographic and Baseline Characteristics (N = 45) Demographic variable Total% / M (SD) Age 42.9 (10.4) Sex Men 88.6% Women 11.4% Marital status Never married 22.7% Married 22.7% Divorced 47.7% Separated 4.5% Remarried 2.3% Substances used Alcohol 68.6% Marijuana 54.3% Sedatives/tranquilizers 15.2% Cocaine/crack 14.8% Opiates 17.1% IV opiate use 6.5% Service/branch Army 34.1% Navy 25.0% Marines 36.4% Reserves/National Guard 4.5% Ethnicity Hispanic 27.3% Non-Hispanic 72.7% Race White 72.7% Black 13.6% Bi/multi-racial 13.6% Pacific Islander/Asian 0% American Indian/Alaskan 0% Other 0% Height (inches) 69.2 (4.4) Weight (lbs) 180.8 (33.0) 180 COLVONEN ET AL. Satisfaction Questionnaire, demographics, Insomnia Severity Index, Epworth Sleepiness Scale, and the Pre-Sleep Arousal Scale). Participants were compensated $20.

OSA diagnostic testing procedures were adapted with the help of doctors and staff on the unit to minimize patient burden and dis- ruption of current SARRTP procedures. All consenting and HSAT set-up were done at a time of day when no SARRTP classes were being held. Participants met with a study coordinator to set up and review procedures for the HSAT. All straps and nose cannulas were adjusted and prepared with study staff prior to the overnight testing, and equipment was put at veterans’bedside table. Medical tape was provided to keep the nose cannula andfinger clip in place. A pamphlet was given to participants with a step-by-step guide for setting up HSAT equipment. The HSAT was scored and reviewed by study staff using the American Academy of Medicine scoring rules (3% oxygen desaturation). Any participant with AHI $5 was asked if they wanted a referral to the Pulmonary Sleep Medicine clinic. If the participant consented to referral, HSAT summary data were sent to Sleep Medicine for review and possible PAP treatment.

Measures OSA Diagnosis OSA was diagnosed using an HSAT portable recorder sleep monitoring systems. The HSAT AHI per hour output has anr=.93 when comparing the gold standard polysomnography (Cairns et al., 2014) and is approved for diagnosis in the American Academy of Sleep Medicine (Kapur et al., 2017). We used the NOX T3 HSAT, which has a simple monitor hook-up that the patients can use on their own with rip cords around the chest to measure breathing effort, a nose cannula to measure airflow and pauses in breathing, and afinger clip to measure oxygen desaturation. For individuals wearing a PAP device, the NOX T3 HSAT attaches to the PAP de- vice to capture residual AHI. All recorders were used for one night while on the SARRTP unit. An AHI$5 is considered to be mild, with those$15 being deemed moderate, and those$30 being severe. Historical OSA diagnosis was also retrieved from medical records to see newly diagnosed compared to previous diagnosis.

Insomnia The Insomnia Severity Index (ISI;Morin et al., 2011)isa widely used measure of insomnia with well-established reliability and validity. The ISI consists of 7 items, three of which assess se- verity of insomnia (i.e., degree of difficulty falling asleep, staying asleep, and waking too early). The remaining questions tap satis- faction with sleep pattern, effect of sleep on daytime and social functioning, and concern about current sleep difficulties. Scores range from 0 (no clinically significant insomnia) to 28 (severe clinical insomnia), with a cut-off of 11 suggesting a diagnosis of insomnia (Morin et al., 2011).

Daytime Sleepiness The Epworth Sleepiness Scale (ESS;Johns, 1991) is a validated 8-item questionnaire measuring daytime sleepiness. The questions ask individuals how likely they are to fall asleep, in eight different situations, on a scale of 0 to 3 (Would never dozetoHigh chance of dozing). Scores arefirst totaled, and higher scores indicatehigher severity of daytime sleepiness, with a cut-off of 10 suggest- ing clinically significant daytime sleepiness. Pre-Sleep Arousal The Pre-Sleep Arousal Scale (PSAS;Nicassio et al., 1985)rates the intensity of somatic (8 items) and cognitive (8 items) manifesta- tions of arousal prior to sleep. The PSAS shows strong internal con- sistency and reliability. The PSAS is a 16-item self-administered measure in which participants rate the intensity (1not at allto 5 extremely) of experienced arousal for somatic and cognitive sub- scales. Higher scores indicate higher intensities of pre-sleep arousal.

Daily Sleep Diary Veterans completed a daily sleep diary at baseline and one week prior to discharge from the unit. Veteransfilled out daily in- formation on bedtime, sleep latency, number and duration of awakenings, wake time, total time in bed, sleep quality, and night- mares. Researchers then calculated two variables (total sleep time and sleep efficiency) based on participant daily entries. The pri- mary outcome measure used for this study was sleep efficiency, defined as the percent time spent sleeping given the number of hours in bed.

PTSD Severity The PTSD Checklist (Weathers et al., 2013) is a 20-item self- report measure of PTSD symptoms with good psychometric prop- erties. The measure maps directly ontoDSM-Vdiagnostic criteria.

Substance Use The Substance Use Inventory asks about the participant’s use of various substances, including alcohol, cocaine, heroin, marijuana, sedatives, PCP, stimulants, and hallucinogens, in the past 30 days, prior to SARRTP intake. The frequency, amount, and administra- tion route (smoked, oral, injected) were also assessed, along with questions about cravings and urges to use.

Alcohol Use The Alcohol Use Disorders Identification test (Saunders, 1989) is a 10-item screening tool assessing alcohol consumption, drink- ing behaviors, and alcohol-related problems such as dependence or experience of alcohol-related harm in the month before SARRTP admission. Scores above 8 are considered hazardous or harmful alcohol use, while scores above 15 indicate high likeli- hood of alcohol dependence.

Cannabis Use The Cannabis Use Disorder Identification Test—Revised (Ad- amson et al., 2010) is an 8-item self-report measuring marijuana use (e.g., yes/no) and behaviors regarding the use of marijuana.

Scores above 8 are considered hazardous or harmful cannabis use, while scores above 12 indicate high likelihood of cannabis use disorder.

Feasibility OSA testing feasibility was assessed via number of veterans that successfully completed OSA diagnostic testing with the HSAT. DIAGNOSING OSA AMONG VETERANS WITH SUD AND PTSD 181 Satisfaction The Client Satisfaction Questionnaire (Larsen et al., 1979) was revised by study staff to assess acceptability of OSA diagnostic testing. Individual questions asked the following: a) How useful was the Obstructive Sleep Apnea screening (NOX T-3) you received? b) Did you receive the information you wanted regard- ing your sleep? c) Would you recommend this process to other veterans on the unit? and d) How satisfied are you with the screen- ing process? Results were on a 4-point Likert scale ranging from 1 (Poor/No,Definitely Not/Quite Dissatisfied)to4(Excellent/Yes, Definitely/Very Satisfied). This instrument was used to measure participants’satisfaction with the intervention following HSAT testing, with higher score indicating higher satisfaction.

Demographics Demographics questions were used to assess weight, ethnicity, race, height, relationship status, and service history.

Data Analysis Data were analyzed with descriptive statistics and paired sample t-tests using SPSS Version 26. Results Feasibility Forty-five (95.7%) of the veterans successfully wore the HSAT for the testing night and successfully completed objective OSA di- agnosis testing; 2 veterans withdrew from the study after consent- ing. One hundred percent of the veterans who attempted the HSAT successfully completed objective OSA testing.

Acceptability Of the 45 veterans who wore the HSAT, 82.2% (n=37) stated that both the usefulness of the OSA diagnosis and ease of the test- ing process were“Excellent,”with the remaining 17.8% of veter- ans (n=8) stating the process was“Good.”Thirty-three (73.3%) of the veterans said they would“Definitely”recommend the test- ing to other veterans, with the remaining 26.6% of veterans (n= 12)saying they“Probably”would recommend the OSA diagnostic testing. Finally, 44.4% (n= 20) of the veterans stated they were “Very Satisfied”with the process, and 55.6% (n= 25) of the veter- ans were“Mostly Satisfied.”Zero percent of respondents stated the process was“Not at all useful/feasible,”“Quite dissatisfied,” or“Would not recommend at all.” OSA Diagnoses Based on the overnight sleep studies, 53.3% of the veterans (n=24) met criteria for a diagnosis of OSA, although some veter- ans were already successfully treating their OSA with a PAP device on the unit. Specifically, 35.6% (n=16) were newly diag- nosed, 8.9% (n=4) were previously diagnosed with OSA and were actively using a PAP, 8.9% (n= 4) had previously been diag- nosed with the current recording confirming the diagnosis but were not using PAP, and 46.7% (n=21) had no OSA (SeeFigure 1). Finally, of the 20 veterans with untreated OSA (16 newly diagnosed and 4 veterans with reconfirmed OSA but not using their PAP treatment), 70.0% (n=14) consented to a pulmo- nary sleep clinic referral for PAP treatment. Baseline Differences by OSA Diagnosis Although the participants fell into four groups (newly diagnosed OSA, previously diagnosed OSA using PAP on unit, previously diagnosed OSA without a PAP on unit, and no OSA), we combined them into two groups based on their symptoms: OSA symptomatic group (AHI$5) and OSA negative/OSA treated group (AHI,5).

The OSA symptomatic group included the newly diagnosed OSA veterans and the previously diagnosed OSA veterans who were not wearing PAP on the unit. The OSA negative/nonsymptomatic group included the veterans negative for OSA or previously diagnosed with OSA but actively using PAP. We examined baseline differences between these two groups and found no differences in PTSD, ESS, ISI, or sleep efficiency (seeTable 2). Discussion This study suggests that objective testing for OSA is feasible and acceptable for veterans with SUD and PTSD in a residential setting. Of the 47 veterans who consented, only 2 veterans declined to participate in the study and 45 veterans successfully received testing, showing 95.7% feasibility. We believe that the 2 veterans who withdrew before the overnight HSAT was scheduled withdrew due to study burden (questionnaires, sleep diary, and HSAT) at a vulnerable time in recovery. Of the veterans who attempted to wear the HSAT, 100% were successful in completing the overnight study and received accurate AHIs. Further, we received positive feedback on the acceptability of the overnight HSAT test, with 100% of respondents saying they were“mostly satisfied”or better with the overall process.

We found that 53.3% of veterans had a diagnosis of OSA.

While 55.6% of participants either did not have OSA or were suc- cessfully treating it with PAP, 44.5% of veterans would have been left untreated on the residential unit without HSAT testing. The number of veterans on the residential unit with untreated OSA is alarmingly high given the potential detrimental effects of untreated OSA on SUD and PTSD outcomes (Colvonen, Straus, et al., 2018; Figure 1 OSAObjectiveTestingWithVeteransontheSARRTP PTSD Track, Including Those With Positive Airway Pressure (PAP) Treatment 46.70% 35.60% 8.90%8.90% Diagnosis (Dx) of OSA No OSA New OSA Previous Dx w/ PAP* Previous Dx w/o PAP* 182 COLVONEN ET AL. Wang & Teichtahl, 2007). The large percentage of veterans in res- idential treatment with untreated OSA also offers a unique oppor- tunity for early evidence-based intervention. While PAP is the gold-standard treatment for OSA, adherence rates are low among veterans with PTSD (Colvonen, Straus, et al., 2018). For example, a recent meta-analysis found that PAP adherence was lower in patients with both OSA and PTSD than OSA alone (Zhang et al., 2017). Early adherence is key to long-term adherence rates for PAP (Budhiraja et al., 2007;Weaver et al., 1997), which suggests that patients should receive follow-ups early after PAP initiation to address any concerns (e.g., claustrophobia) and assist with titra- tion and maskfit(Drake et al., 2003). Due to the dose response of PAP with positive outcomes, increasing adherence to PAP with desensitization to the mask may be essential to help veterans with PTSD (Goldstein et al., 2017). Residential care may be a uniquely stable and supportive environment to initiate PAP therapy due to the reduced external stressors and distractions, controlled environ- ment with professional support, increased structure and account- ability (e.g., more likely to attend sessions and follow through on treatment planning), and increasing access to clinicians to help intervene and motivate individuals (Haller et al., 2019). Future studies should examine whether evidence-based treatment for OSA on a residential unit leads to improved SUD/PTSD treatment outcomes.

While we hypothesized that veterans with untreated OSA would have worse SUD, PTSD, and sleep severity, our results did not support this. We found no differences between untreated OSA and the treated or no OSA group on any baseline measures of sleep, substance use, or PTSD severity. We believe that this has to do with the ceiling effects of SUD, PTSD, and sleep severity among veterans just entering residential care, minimizing the variability necessary tofind associations. Another possibility is our small sample size limiting the power necessary to detect differences.

Thesefindings may suggest that, in certain settings, symptom se- verity cannot be used as an indicator of high risk for OSA.We recommend integrating objective OSA diagnostic testing into residential care for all residents whether or not they show classic risk factors for OSA (e.g., high BMI or older age). First, as previously mentioned, symptom severity does not discriminate between OSA positive/negative. Second, there is increasing evi- dence that self-report questionnaires for“high risk of OSA”are not accurate as screeners for veterans or PTSD (Kunisaki et al., 2014;Lyons et al., 2021;McMahon et al., 2017). Together, there are no predictable visual, symptomatic, or self-report screeners to indicate who is in need of PAP treatment.

Our study has several limitations, including the small sample size and lack of follow-up data. As such, the long-term effects of PAP treatment on SUD and PTSD outcomes are unclear. Given these limitations, this study is best viewed as an objective testing protocol development and will require examination of PAP treat- ment and how that affects SUD and PTSD outcomes. However, this study offers strong support for the importance of diagnostic testing for OSA for individuals with SUD and PTSD while in a residential care setting. Objective testing, and possibly treatment, for OSA is feasible and acceptable in a residential care setting. References Adamson, S. J., Kay-Lambkin, F. J., Baker, A. L., Lewin, T. J., Thornton, L., Kelly, B. J., & Sellman, J. D. (2010). An improved brief measure of cannabis misuse: The Cannabis Use Disorders Identification Test-Re- vised (CUDIT-R).Drug and Alcohol Dependence,110(1–2), 137–143.

https://doi.org/10.1016/j.drugalcdep.2010.02.017 Alexander, M., Ray, M. A., Hébert, J. R., Youngstedt, S. D., Zhang, H., Steck, S. E., Bogan R. K., & Burch, J. B. (2016). The national veteran sleep disorder study: Descriptive epidemiology and secular trends, 2000–2010.Sleep,39(7), 1399–1410.https://doi.org/10.5665/sleep.5972 Angarita, G. A., Emadi, N., Hodges, S., & Morgan, P. T. (2016). Sleep abnormalities associated with alcohol, cannabis, cocaine, and opiate use:

A comprehensive review.Addiction Science & Clinical Practice,11(1), Article 9.https://doi.org/10.1186/s13722-016-0056-7 Table 2 Clinical Variables by Symptomatic and Non-Symptomatic OSA (N = 45) Symptomatic OSA (n= 19) No OSA symptoms (n= 26) MeasuresM(SD)M(SD)tCohen’sd Health measure AHI 12.32 (6.99) 3.59 (7.05) 4.11 ** 1.24 BMI 27.22 (3.87) 26.51 (3.83) 0.59 0.18 Systolic blood pressure 126.95 (21.45) 121.04 (11.04) 1.19 0.35 Diastolic blood pressure 78.95 (11.48) 77.80 (8.33) 0.38 0.11 Neck circumference (cm) 41.22 (3.43) 41.18 (3.47) 0.03 0.01 Questionnaire Insomnia Severity Index 16.28 (5.04) 17.83 (5.39) 0.93 0.30 Epworth Sleepiness Scale 9.43 (4.72) 10.57 (5.40) 0.64 0.22 PTSD Checklist 54.11 (12.52) 54.36 (11.61) 0.07 0.02 Beck Depression Inventory 27.17 (9.27) 27.30 (12.27) 0.03 0.01 Alcohol Use Disorders Identification Test 24.59 (7.73) 19.47 (11.66) 1.53 0.52 Cannabis Use Disorders Identification Test 7.00 (9.79) 11.59 (10.30) 1.46 0.46 Sleep diary variables Sleep efficiency (%) 77.94% (7.82) 83.96% (8.19) 0.94 0.75 Average nightmares (per night) 0.73 (0.80) 1.09 (0.89) 1.21 0.35 Note. AHI = Apnea Hypopnea Index; BMI = Body mass index. No OSA Symptoms group consists of OSA negative and OSA positive with active posi- tive airway pressure use.

**p,.001.DIAGNOSING OSA AMONG VETERANS WITH SUD AND PTSD 183 Antic, N. A., Catcheside, P., Buchan, C., Hensley, M., Naughton, M. T., Rowland, S., Williamson, B., Windler, S., & McEvoy, R. D. (2011).

The effect of CPAP in normalizing daytime sleepiness, quality of life, and neurocognitive function in patients with moderate to severe OSA.

Sleep,34(1), 111–119.https://doi.org/10.1093/sleep/34.1.111 Block, A. J., & Hellard, D. W. (1987). Ingestion of either scotch or vodka induces equal effects on sleep and breathing of asymptomatic subjects.

Archives of Internal Medicine,147(6), 1145–1147.https://doi.org/10 .1001/archinte.1987.00370060141023 Brower, K. J. (2003). Insomnia, alcoholism and relapse.Sleep Medicine Reviews,7(6), 523–539.https://doi.org/10.1016/S1087-0792(03)90005-0 Brower, K. J., Aldrich, M. S., Robinson, E. A., Zucker, R. A., & Greden, J. F. (2001). Insomnia, self-medication, and relapse to alcoholism.The American Journal of Psychiatry,158(3), 399–404.https://doi.org/10 .1176/appi.ajp.158.3.399 Budhiraja, R., Parthasarathy, S., Drake, C. L., Roth, T., Sharief, I., Budhiraja, P., Saunders, V., & Hudgel, D. W. (2007). Early CPAP use identifies subsequent adherence to CPAP therapy.Sleep,30(3), 320–324.

Cairns, A., Wickwire, E., Schaefer, E., & Nyanjom, D. (2014). A pilot val- idation study for the NOX T3(TM) portable monitor for the detection of OSA.Sleep and Breathing,18(3), 609–614.https://doi.org/10.1007/ s11325-013-0924-2 Calabrese, J. R., Prescott, M., Tamburrino, M., Liberzon, I., Slembarski, R., Goldmann, E., Shirley, E., Fine, T., Goto, T., & Wilson, K. (2011).

PTSD comorbidity and suicidal ideation associated with PTSD within the Ohio Army National Guard.The Journal of Clinical Psychiatry, 72(8), 1072–1078.https://doi.org/10.4088/JCP.11m06956, Colvonen, P. J., Ellison, J., Haller, M., & Norman, S. B. (2018). Examin- ing insomnia and PTSD over time in veterans in residential treatment for substance use disorders and PTSD.Behavioral Sleep Medicine,17(4), 524–535.https://doi.org/10.1080/15402002.2018.1425869 Colvonen, P. J., Masino, T., Drummond, S. P., Myers, U. S., Angkaw, A. C., & Norman, S. B. (2015). Obstructive sleep apnea and posttrau- matic stress disorder among OEF/OIF/OND veterans.Journal of Clini- cal Sleep Medicine,11(5), 513–518.https://doi.org/10.5664/jcsm.4692 Colvonen, P. J., Straus, L. D., Stepnowsky, C., McCarthy, M. J., Goldstein, L. A., & Norman, S. B. (2018). Recent advancements in treating sleep disorders in co-occurring PTSD.Current Psychiatry Reports, 20(7), Article 48.https://doi.org/10.1007/s11920-018-0916-9 Dawson, A., Lehr, P., Bigby, B. G., & Mitler, M. M. (1993). Effect of bed- time ethanol on total inspiratory resistance and respiratory drive in nor- mal nonsnoring men.Alcoholism, Clinical and Experimental Research, 17(2), 256–262.https://doi.org/10.1111/j.1530-0277.1993.tb00759.x Drake, C. L., Day, R., Hudgel, D., Stefadu, Y., Parks, M., Syron, M. L., & Roth, T. (2003). Sleep during titration predicts continuous positive airway pressure compliance.Sleep,26(3), 308–311.https://doi.org/10.1093/sleep/ 26.3.308 Driessen, M., Schulte, S., Luedecke, C., Schaefer, I., Sutmann, F., Ohlmeier, M., Havemann, R. U.,. . . The TRAUMAB-Study Group.

(2008). Trauma and PTSD in patients with alcohol, drug, or dual de- pendence: A multi-center study.Alcoholism, Clinical and Experimental Research,32(3), 481–488.https://doi.org/10.1111/j.1530-0277.2007 .00591.x El-Ad, B., & Lavie, P. (2005). Effect of sleep apnea on cognition and mood.International Review of Psychiatry,17(4), 277–282.https://doi .org/10.1080/09540260500104508 Gagnon, K., Baril, A. A., Gagnon, J. F., Fortin, M., Décary, A., Lafond, C., . . . Gosselin, N. (2014). Cognitive impairment in obstructive sleep apnea.Pathologie Biologie,62(5), 233–240.https://doi.org/10.1016/j .patbio.2014.05.015 Goldstein, L. A., Colvonen, P. J., & Sarmiento, K. F. (2017). Advancing treatment of comorbid PTSD and OSA.Journal of Clinical Sleep Medi- cine,13(6), 843–844.https://doi.org/10.5664/jcsm.6638Haller, M., Norman, S. B., Davis, B. C., Sevcik, J., Lyons, R., & Erickson, F. (2019). Treating PTSD in a residential substance use disorder treat- ment program. In A. A. Vujanovic & S. E. Back (Eds.),Posttraumatic stress and substance use disorders: A comprehensive clinical handbook (pp. 310–325). Routledge.

Jennum, P., & Kjellberg, J. (2011). Health, social and economical conse- quences of sleep-disordered breathing: A controlled national study.

Thorax,66(7), 560–566.https://doi.org/10.1136/thx.2010.143958 Johns, M. W. (1991). A new method for measuring daytime sleepiness:

The Epworth Sleepiness Scale.Sleep,14(6), 540–545.https://doi.org/10 .1093/sleep/14.6.540 Kapur, V. K., Auckley, D. H., Chowdhuri, S., Kuhlmann, D. C., Mehra, R., Ramar, K., & Harrod, C. G. (2017). Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: An American Acad- emy of Sleep Medicine clinical practice guideline.Journal of Clinical Sleep Medicine,13(3), 479–504.https://doi.org/10.5664/jcsm.6506 Kessler, R. C., Chiu, W. T., Demler, O., Merikangas, K. R., & Walters, E. E. (2005). Prevalence, severity, and comorbidity of 12-month DSM–IVdisorders in the National Comorbidity Survey Replication.Ar- chives of General Psychiatry,62(6), 617–627.https://doi.org/10.1001/ archpsyc.62.6.617 Krakow, B., Melendrez, D., Warner, T. D., Clark, J. O., Sisley, B. N., Dorin, R., . . . Hollifield, M. (2006). Signs and symptoms of sleep-disor- dered breathing in trauma survivors: A matched comparison with classic sleep apnea patients.Journal of Nervous and Mental Disease,194(6), 433–439.https://doi.org/10.1097/01.nmd.0000221286.65021.e0 Kunisaki, K. M., Brown, K. E., Fabbrini, A. E., Wetherbee, E. E., & Rector, T. S. (2014). STOP-BANG questionnaire performance in a Vet- erans Affairs unattended sleep study program.Annals of the American Thoracic Society,11(2), 192–197.https://doi.org/10.1513/AnnalsATS .201305-134OC Larsen, D. L., Attkisson, C. C., Hargreaves, W. A., & Nguyen, T. D.

(1979). Assessment of client/patient satisfaction: Development of a gen- eral scale.Evaluation and Program Planning,2(3), 197–207.https://doi .org/10.1016/0149-7189(79)90094-6 Le Bon, O., Verbanck, P., Hoffmann, G., Murphy, J. R., Staner, L., De Groote, D.,. . . Pelc, I. (1997). Sleep in detoxified alcoholics: Impair- ment of most standard sleep parameters and increased risk for sleep apnea, but not for myoclonias—A controlled study.Journal of Studies on Alcohol,58(1), 30–36.https://doi.org/10.15288/jsa.1997.58.30 Lettieri, C. J., Williams, S. G., & Collen, J. F. (2016). OSA syndrome and posttraumatic stress disorder: Clinical outcomes and impact of positive airway pressure therapy.Chest,149(2), 483–490.https://doi.org/10.1378/ chest.15-0693 Lyons, R., Barbir, L., Norman, S. B., Owens, R., & Colvonen, P. J. (2021).

Examining the association between subjective and objective measures of obstructive sleep apnea risk in veterans with posttraumatic stress disor- der and insomnia. VA San Diego Healthcare System.

Mahfoud, Y., Talih, F., Streem, D., & Budur, K. (2009).Sleep disorders in substance abusers: How common are they? Psychiatry,6(9), 38–42.

Mamdani, M., Hollyfield, R., Ravi, S. D., Dorus, W., & Borge, G. F.

(1989). Prevalence of sleep apnea among abstinent chronic alcoholic men.Sleep Research,18, 349.

McMahon, M. J., Sheikh, K. L., Andrada, T. F., & Holley, A. B. (2017).

Using the STOPBANG questionnaire and other pre-test probability tools to predict OSA in younger, thinner patients referred to a sleep medicine clinic.Sleep and Breathing,21(4), 869–876.https://doi.org/10.1007/ s11325-017-1498-1 Mesa, F., Dickstein, B. D., Wooten, V. D., & Chard, K. M. (2017).

Response to cognitive processing therapy in veterans with and without obstructive sleep apnea.Journal of Traumatic Stress,30(6), 646–655.

https://doi.org/10.1002/jts.22245 Morin, C. M., Belleville, G., Bélanger, L., & Ivers, H. (2011). The Insom- nia Severity Index: Psychometric indicators to detect insomnia cases 184 COLVONEN ET AL. and evaluate treatment response.Sleep,34(5), 601–608.https://doi.org/ 10.1093/sleep/34.5.601 Najavits, L. M., Norman, S. B., Kivlahan, D., & Kosten, T. R. (2010).

Improving PTSD/substance abuse treatment in the VA: A survey of pro- viders.The American Journal on Addictions,19(3), 257–263.https://doi .org/10.1111/j.1521-0391.2010.00039.x Nicassio, P. M., Mendlowitz, D. R., Fussell, J. J., & Petras, L. (1985). The phenomenology of the pre-sleep state: The development of the pre-sleep arousal scale.Behaviour Research and Therapy,23(3), 263–271.https:// doi.org/10.1016/0005-7967(85)90004-X Norman, S. B., Davis, B. C., Colvonen, P. J., Haller, M., Myers, U. S., Trim, R. S., . . . Robinson, S. K. (2016). Prolonged exposure with veter- ans in a residential substance use treatment program.Cognitive and Be- havioral Practice,23(2), 162–172.https://doi.org/10.1016/j.cbpra.2015 .08.002 Norman, S. B., Haller, M., Hamblen, J. L., Southwick, S. M., & Pietrzak, R. H. (2018). The burden of co-occurring alcohol use disorder and PTSD in U.S. Military veterans: Comorbidities, functioning, and suici- dality.Psychology of Addictive Behaviors,32(2), 224–229.https://doi .org/10.1037/adb0000348 Patil, S. P., Ayappa, I. A., Caples, S. M., Kimoff, R. J., Patel, S. R., & Harrod, C. G. (2019). Treatment of adult obstructive sleep apnea with positive airway pressure: An American Academy of Sleep Medicine clinical practice guidelineJournal of Clinical Sleep Medicine,15(2), 335–343.

Possemato, K., Wade, M., Andersen, J., & Ouimette, P. (2010). The impact of PTSD, depression, and substance use disorders on disease burden and health care utilization among OEF/OIF veterans.Psychological Trauma:

Theory, Research, Practice, and Policy,2(3), 218–223.https://doi.org/ 10.1037/a0019236 Proctor, S. L., & Herschman, P. L. (2014). The continuing care model of substance use treatment: What works, and when is“enough,”“enough?

Psychiatry Journal,2014, Article 692423.https://doi.org/10.1155/2014/ 692423 Redline, S., Yenokyan, G., Gottlieb, D. J., Shahar, E., O’Connor, G. T., Resnick, H. E.,. . . Punjabi, N. M. (2010). Obstructive sleep apnea- hypopnea and incident stroke: The sleep heart health study.American Journal of Respiratory and Critical Care Medicine,182(2), 269– 277.

https://doi.org/10.1164/rccm.200911-1746OC Reist, C., Gory, A., & Hollifield, M. (2017). Sleep-disordered breathing impact on efficacy of prolonged exposure therapy for posttraumatic stress disorder.Journal of Traumatic Stress,30(2), 186–189.https://doi .org/10.1002/jts.22168 Rezaeitalab, F., Mokhber, N., Ravanshad, Y., Saberi, S., & Rezaeetalab, F.

(2018). Different polysomnographic patterns in military veterans with obstructive sleep apnea in those with and without post-traumatic stress disorder.Sleep and Breathing,22,17–22.https://doi.org/10.1007/ s11325-017-1596-0 Robinson, R. W., White, D. P., & Zwillich, C. W. (1985). Moderate alco- hol ingestion increases upper airway resistance in normal subjects.The American Review of Respiratory Disease,132(6), 1238–1241.

Rose, A. R., Catcheside, P. G., McEvoy, R. D., Paul, D., Kapur, D., Peak, E., . . . Antic, N. A. (2014). Sleep disordered breathing and chronic re- spiratory failure in patients with chronic pain on long term opioid ther- apy.Journal of Clinical Sleep Medicine,10(8), 847–852.https://doi.org/ 10.5664/jcsm.3950 Saunders, G. H. (1989). Determinants of objective and subjective auditory disability in patients with normal hearing.University of Nottingham.

Scanlan, M. F., Roebuck, T., Little, P. J., Redman, J. R., & Naughton, M. T. (2000). Effect of moderate alcohol upon obstructive sleep apnoea.

The European Respiratory Journal,16(5), 909–913.https://doi.org/10 .1183/09031936.00.16590900Schwab, R., Goldberg, A., & Pack, A. (1998). Sleep apnea syndromes. InFish- man’s pulmonary diseases and disorders(pp. 1617–1637). McGraw-Hill Book Company.

Schwartz, M., Acosta, L., Hung, Y.-L., Padilla, M., & Enciso, R. (2018).

Effects of CPAP and mandibular advancement device treatment in ob- structive sleep apnea patients: A systematic review and meta-analysis.

Sleep and Breathing,22(3), 555–568.https://doi.org/10.1007/s11325 -017-1590-6 Senaratna, C. V., Perret, J. L., Lodge, C. J., Lowe, A. J., Campbell, B. E., Matheson, M. C.,. . . Dharmage, S. C. (2017). Prevalence of obstructive sleep apnea in the general population: A systematic review.Sleep Medi- cine Reviews,34,70–81.https://doi.org/10.1016/j.smrv.2016.07.002 Sharafkhaneh, A., Giray, N., Richardson, P., Young, T., & Hirshkowitz, M. (2005). Association of psychiatric disorders and sleep apnea in a large cohort.Sleep,28(11), 1405–1411.https://doi.org/10.1093/sleep/28 .11.1405 Stahler, G. J., Mennis, J., & DuCette, J. P. (2016). Residential and outpa- tient treatment completion for substance use disorders in the U.S.: Mod- eration analysis by demographics and drug of choice.Addictive Behaviors,58, 129–135.https://doi.org/10.1016/j.addbeh.2016.02.030 Substance Abuse and Mental Health Services Administration. (2008).

Treatment Episode Data Set (TEDS) 1996–2006.

Vitiello, M. V., Prinz, P. N., Personius, J. P., Vitaliano, P. P., Nuccio, M. A., & Koerker, R. (1990). Relationship of alcohol abuse history to nighttime hypoxemia in abstaining chronic alcoholic men.Journal of Studies on Alcohol,51(1), 29–33.https://doi.org/10.15288/jsa.1990.51.29 Wang, D., & Teichtahl, H. (2007). Opioids, sleep architecture and sleep- disordered breathing.Sleep Medicine Reviews,11(1), 35–46.https://doi .org/10.1016/j.smrv.2006.03.006 Weathers, F. W., Litz, B. T., Keane, T. M., Palmieri, P. A., Marx, B. P., & Schnurr, P. P. (2013).The PTSD Checklist for DSM-5 (PCL-5). Avail- able atwww.ptsd.va.gov Weaver, T. E., Kribbs, N. B., Pack, A. I., Kline, L. R., Chugh, D. K., Maislin, G.,. . . Dinges, D. F. (1997). Night-to-night variability in CPAP use over the first three months of treatment.Sleep,20(4), 278–283.https://doi.org/10.1093/sleep/20.4.278 Williams, S. G., Collen, J., Orr, N., Holley, A. B., & Lettieri, C. J. (2015).

Sleep disorders in combat-related PTSD.Sleep and Breathing,19(1), 175–182.https://doi.org/10.1007/s11325-014-0984-y Yesavage, J. A., Kinoshita, L. M., Kimball, T., Zeitzer, J., Friedman, L., Noda, A.,...O’Hara, R. (2012). Sleep-disordered breathing in Vietnam veterans with posttraumatic stress disorder.The American Journal of Geriatric Psychiatry,20(3), 199–204.https://doi.org/10.1097/JGP.0b013 e3181e446ea Young, T., Finn, L., Peppard, P. E., Szklo-Coxe, M., Austin, D., Nieto, F. J., . . . Hla, K. M. (2008). Sleep disordered breathing and mortality:

Eighteen-year follow-up of the Wisconsin sleep cohort.Sleep,31(8), 1071–1078.

Young, T., Peppard, P. E., & Gottlieb, D. J. (2002). Epidemiology of ob- structive sleep apnea: A population health perspective.American Jour- nal of Respiratory and Critical Care Medicine,165(9), 1217–1239.

https://doi.org/10.1164/rccm.2109080 Zhang, Z., Friedmann, P. D., & Gerstein, D. R. (2003). Does retention mat- ter? Treatment duration and improvement in drug use. Addiction,98(5), 673–684.https://doi.org/10.1046/j.1360-0443.2003.00354.x Zhang, Y., Weed, J. G., Ren, R., Tang, X., & Zhang, W. (2017). Preva- lence of obstructive sleep apnea in patients with posttraumatic stress dis- order and its impact on adherence to continuous positive airway pressure therapy: A meta-analysis.Sleep Medicine,36, 125–132.https:// doi.org/10.1016/j.sleep.2017.04.020 Received October 17, 2020 Revision received February 12, 2021 Accepted April 2, 2021 n DIAGNOSING OSA AMONG VETERANS WITH SUD AND PTSD 185